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SAN JOAQUIN COUNTY I <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N: 1 <br /> OF <br /> +, d '. 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> ``�ii;�d;:•t� Telephone:(209)468-3147 Fax:(209)4G8-3433 Web:vvvrvr,slgov.olgloft <br /> UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application Is made In compliance%vith San <br /> Joaquin County Development Title,Chapter 9.1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location'I' 00G(oc.K Jr) /1d-0—_Cross Street - s.INa,IA _ CIIy/Stale� Ztp c/SZ/-5— APN 1'Z32-0001 <br /> Property V <br /> Owner Address 1'7 llnure'o C-A- City/Slalelo)(�Zip%� Phone`//S-3F)3 -4y0v <br /> C•57Contractor Ljcrc(Wz,�A 1�r It Address lt:.ur khi�,O,l3Cr 33ia CilylSlale�:ol�.a l.. Lle IBJ' c Phcneh0`1 -37.11300 <br /> ConsultanUSubCntr6-W D Address'Z23s(d c��/(�<.v�iIt,E0 Cily/Slate A-4r•Q VLic Phone-701-5'13"!121 0 <br /> Blllahle Party G 1-E 0 Address mu-cvry Wcv ,S4e I';0 CilylSlate 5 ..1r-114 Ztpct•S J Phone701 5`23 (010 <br /> GIS Coordinates:X 3 S�a�sy7r 2 1'105Yj_D 2 <br /> CONSTRUCTION WORK TOE PERFORMED: <br /> [I NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _I]htONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑t.iULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Vlater ❑HAMkIERIDRNEN CASING THICKNESS TYPE OF CASING: [I STEEL E]PVC❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑I.iUD ROTARY DEPTH OF GROUT SEAL TREttIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING D PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIbiUM FREE FALL DEPTH IS JO FT) <br /> _❑INJECTION Re AIrsparea.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH C1 BOLTED TRAFFIC BOX OR [3 STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Cas:'ng Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY <br /> t <br /> Z #OF WELLS)TO BE DESTROYED &OVER-BORE DIAMETER OF c _INCHES TO DEPTH OF �D FT <br /> WELL IDs: fI/L W- l-( IV1 la '- S` _ ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS �+4 4- 3`>� 6v-- ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE G�PtPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS G'rCA CL Liz ti/{tfs lJer��Csc( i 5��awtclIC eals=w( <br /> 6 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have propared)hls application and(list the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Repulatt6ns,an II a >I;able-Call brnla laws, <br /> Signed_ l , pt�t/✓G it Tiile/Company Par Gil l�6✓SLG h� <br /> Print Nam- �7�w� a v0 S S cal• Dale—/-t3�7$��U l <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS qQ Yo E M p N 5SRC-G—% 5 fi,Cts <br /> WORK PLAN DATED Oen B�e 23 2";'I 3 <br /> APPLICATION ACCEPTED BYcw r Ku wt DATE ISSUED (U�L4`/ '1 AREA iG q 9q 9 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK II RECV'D BY DATE REQUEST PRO <br /> �.4D2 8125x2 z$o (pZ 17( )87 0, /o- SRI/ <br /> 375 375 Roo/ <br /> PRI/ <br /> (2800) <br /> C-57 t-' WC WAIVER Ptl­ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS <br /> EHD 29.01 5109112 WELL PERMITAPP <br />